1
|
Demirbuğa A, Hançerli Törün S, Metin-Akcan Ö, Yücel A, Yahşi A, Bayhan Gİ, Emre I, Öztürk B, Kaba Ö, Kutluk G, Tural-Kara T, Erbaş İC, Özdem-Alataş Ş, Akça M, Özgökçe-Özmen B, Aslan S, Çakici Ö. The Role of Adenovirus in Hepatitis of Unknown Etiology Among Children in Turkey, July 2022 to January 2023. Pediatr Infect Dis J 2024; 43:1-6. [PMID: 37725812 DOI: 10.1097/inf.0000000000004094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND In the first half of 2022, the increase in cases of severe acute hepatitis in children with no epidemiological link and unknown cause has aroused concern worldwide. In this study, we aimed to determine the frequency of adenovirus in children with hepatitis of unknown origin in Turkey. METHODS In this study, which was conducted with the participation of 16 centers from Turkey, between July 2022 and January 2023, 36 pediatric patients under the age of 18 who met the definition of acute hepatitis were included. RESULTS Twenty (55,6%) of patients were female and 16 (44,4%) were male, with a mean age of 41.55 ± 39.22 (3-192) months. The most common symptoms were fever (66.7%), weakness (66.7%), loss of appetite (66.7%), fatigue (61.1%), vomiting (61.1%), and diarrhea (47.2%). Six (16 %) children had acute hepatic failure. Eight of the 15 children (46%) had respiratory viral infections (rhinovirus/enterovirus, n = 4; rhinovirus + parainfluenza, n = 1; parainfluenza, n = 1, SARS-CoV-2 n = 2). Adenovirus was detected in 16 (44%) patients. Adenovirus and coinfections were detected in 7 patients. History of diarrhea and fatigue in the last month was significantly higher in the adenovirus group ( P = 0.023 and 0.018). One child who had both adenovirus and rhinovirus infection required liver transplantation; all others recovered with supportive care. CONCLUSION There were no deaths in our series; however, the number of cases, etiology, and severity of the clinical course may have differed between countries owing to differences in case definitions, laboratory facilities, or regional genetic differences.
Collapse
Affiliation(s)
- Asuman Demirbuğa
- From the Department of Pediatrics, Division of Pediatric Infectious Diseases, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Selda Hançerli Törün
- From the Department of Pediatrics, Division of Pediatric Infectious Diseases, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Özge Metin-Akcan
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Necmettin Erbakan University, Meram Hospital, Konya, Turkey
| | - Aylin Yücel
- Department of Pediatrics, Division of Pediatric Gastroenterology Hepatology and Nutrition, Necmettin Erbakan University, Meram Hospital, Konya, Turkey
| | - Aysun Yahşi
- Department of Pediatrics, Division of Pediatric Infectious Disease, Medical Faculty of Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Gülsüm İclal Bayhan
- Department of Pediatrics, Division of Pediatric Infectious Disease, Medical Faculty of Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Irmak Emre
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Okmeydani Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Birol Öztürk
- Department of Pediatrics, Division of Gastroenterology Hepatology and Nutrition, Okmeydani Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Özge Kaba
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Başakşehir Çam and Sakura City of Hospital, Istanbul, Turkey
| | - Günsel Kutluk
- Department of Pediatrics, Division of Gastroenterology Hepatology and Nutrition, Başakşehir Çam and Sakura City of Hospital, Istanbul, Turkey
| | - Tuğçe Tural-Kara
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - İrem Ceren Erbaş
- Department of Pediatrics, Division of Pediatric Infectious Disease, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Şilem Özdem-Alataş
- Department of Pediatrics, Division of Pediatric Infectious Disease, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Mehtap Akça
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Berfin Özgökçe-Özmen
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Sevgi Aslan
- Department of Pediatrics, Division of Gastroenterology Hepatology and Nutrition, Okmeydani Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Özlem Çakici
- Department of Pediatrics, Division of Pediatric Infectious Disease, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| |
Collapse
|
2
|
Li M, Jiang L, Liu S, Xu P, Wei H, Li Y, Guo C, Zhu L, Zhao B, Liu Y, Zhang M, Zhao J. Clinicopathological characteristics of 3 probable pediatric cases with acute severe hepatitis of unknown aetiology. New Microbes New Infect 2024; 56:101203. [PMID: 38146348 PMCID: PMC10749268 DOI: 10.1016/j.nmni.2023.101203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 12/27/2023] Open
Abstract
Background Acute severe hepatitis with unknown aetiology in children (ASHep-UA) has become a global health alert. This article reported clinicopathological characteristics of 3 probable ASHep-UA cases. Methods We respectively collected serological data and liver biopsies of 3 suspected cases of ASHep-UA. Neutralizing antibodies titer for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variants were determined by virus neutralization test (VNT). Histological assessment, immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) for cytomegalovirus (CMV), Epstein-Barr virus (EBV), human adenoviruses (HAdV), adeno-associated virus (AAV2), human herpes virus type 6 (HHV-6) were performed to identify possible aetiologies. Results Remarkable elevation of transaminase (median ALT level, 1100 IU/liter; median AST level, 500 IU/liter) were revealed with undetectable hepatitis A-E and non-hepatotropic virus in both sera and tissues. Weakness, jaundice, pale stools and splenomegaly were observed. Interestingly, two individuals had SARS-CoV-2 Omicron variants infection. Histologically, moderate or severe lobular necroinflammation, active interface hepatitis and portal inflammatory infiltrate with lymphocytic, plasma cells, neutrophils and eosinophilic cells were noted. Conclusions The exact aetiology of ASHep-UA was still unknown. By reporting the 3 probable cases, we expect to enrich the clinical experience in diagnosis and treatment of ASHep-UA as well as the pathological characteristics.
Collapse
Affiliation(s)
- Meiling Li
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lina Jiang
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shuhong Liu
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Pengfei Xu
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Haiyan Wei
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yu Li
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Chaonan Guo
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Li Zhu
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Bokang Zhao
- Department of Hepatology, Center of Infectious Diseases and PathogenBiology, The First Hospital of Jilin University, Changchun, China
| | - Yisi Liu
- First Department of Liver Disease Center, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Min Zhang
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jingmin Zhao
- The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
3
|
Mehta S, John T, Feld JJ, Shah H, Mullaithilaga N, Campigotto A, Leung K, Kamath BM, Ling SC, Science M, Ng VL. Severe acute hepatitis of unknown etiology in a large cohort of children. Hepatol Commun 2023; 7:e0272. [PMID: 37756118 PMCID: PMC10531196 DOI: 10.1097/hc9.0000000000000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/18/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND We evaluated the proportion, clinical features, and outcomes of previously healthy children presenting to a large Canadian quaternary pediatric center with severe acute hepatitis of unknown etiology. METHODS All patients with serum alanine aminotransferase (ALT) > 500 U/L or aspartate aminotransferase (AST) > 500 U/L between June 1, 2018, and May 31, 2022, at The Hospital for Sick Children, were identified. Subjects with only AST > 500 U/L were excluded. Clinical characteristics, investigations, and outcomes for patients without clear etiology for ALT > 500 U/L (severe acute hepatitis of unknown etiology) for our study period and from October 1 to May 31 of each year 2018-2021 were reviewed. RESULTS Of 977 patients with ALT/AST> 500 U/L, 720 had only ALT > 500 U/L. We excluded age below 6 months (n = 99) or above 16 years (n = 66), known pre-existing liver conditions (n = 66), and ALT > 500 U/L in already admitted patients (n = 151). Among the remaining 338 children with ALT > 500 U/L at presentation, an etiology was identified in 303 subjects. 33 (9.8%) children [median age 6.1 y (range 0.5-15.5); 61% male] were confirmed as severe acute hepatitis of unknown etiology. Twenty patients (60.6%) were tested for blood adenovirus by PCR, and 1 (5%) was positive (serotype B7). Liver tissue specimens from 18 patients revealed no evidence of viral inclusions or adenovirus. Twelve (36.3%) presented with pediatric acute liver failure, with 8 (24.2%) requiring liver transplantation. There were no deaths. Hepatitis-associated aplastic anemia occurred in 5 (15%) patients. CONCLUSIONS Of children presenting with severe acute hepatitis to a quaternary children's hospital over a 48-month period, 9.8% had unknown etiology with no change over time. Liver transplantation remains an important treatment strategy for those presenting with pediatric acute liver failure phenotype. The frequency of cases associated with human adenovirus infection was noncontributory.
Collapse
Affiliation(s)
- Sagar Mehta
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tomisin John
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hemant Shah
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nisa Mullaithilaga
- Department of Paediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Campigotto
- Department of Laboratory Medicine, Division of Microbiology, University of Toronto, Toronto, Ontario, Canada
| | - Karen Leung
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Binita M. Kamath
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Simon C. Ling
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Science
- Department of Paediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vicky L. Ng
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Elbeltagi R, Al-Beltagi M, Saeed NK, Bediwy AS, Toema O. May 2022 acute hepatitis outbreak, is there a role for COVID-19 and other viruses? World J Hepatol 2023; 15:364-376. [PMID: 37034240 PMCID: PMC10075009 DOI: 10.4254/wjh.v15.i3.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/06/2023] [Accepted: 03/14/2023] [Indexed: 03/24/2023] Open
Abstract
There has been an increasing number of reported cases of acute hepatitis of unknown origin in previously healthy children since first reported on March 31, 2022. This clinical syndrome is identified by jaundice and markedly elevated liver enzymes with increased aspartate transaminase and/or alanine aminotransaminase (greater than 500 IU/L). We conducted an inclusive literature review with respect to acute hepatitis outbreaks in children using the search terms acute hepatitis, outbreak, children, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), coronavirus disease 2019 (COVID-19), and adenovirus. According to the cumulative data presented in four main studies, the median age is 4 years, with a male predominance (1.3:1). Jaundice was the most common clinical manifestation (69%), followed by vomiting (63%), anorexia (52.9%), diarrhea (47.2%), abdominal pain (39%), pyrexia (33.3%), pale stool (30%), and dark urine (30%). Coryza and lethargy were reported in 16.6%, while pruritus was reported in 2% of cases. Acute liver failure was observed in 25% of cases. The exact mechanism of this acute hepatitis outbreak is still not entirely clear. Adenoviruses and SARS-CoV-2 were detected in a significant number of patients. Coinfection with adenovirus and SARS-CoV-2 could be a possible underlying mechanism. However, other possible infections and mechanisms must be considered in the pathogenesis of this condition. Acute hepatitis of unknown origin in children has been a serious problem since the start of the COVID-19 pandemic but has not yet been sufficiently addressed. Many questions remain regarding the underlying mechanisms leading to acute liver failure in children, and it is likely that extensive future research is needed.
Collapse
Affiliation(s)
- Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
| | - Mohammed Al-Beltagi
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Al Gharbia, Egypt
- Department of Pediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Nermin Kamal Saeed
- Department of Pathology, Microbiology Section, Salmaniya Medical Complex, Manama 12, Bahrain
- Department of Microbiology, Royal College of Surgeons in Ireland - Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Diseases, Faculty of Medicine, Tanta University, Tanta 31527, Al Gharbia, Egypt
- Department of Chest Diseases, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Osama Toema
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Al Gharbia, Egypt
| |
Collapse
|
5
|
Săndulescu O, Streinu-Cercel A, Miron VD, Covăcescu SM, Streinu-Cercel A, Craiu M. Liver Transaminases in Pediatric Adenovirus Infection-A Five-Year Study in Two Major Reference Centers from Romania. Microorganisms 2023; 11:microorganisms11020302. [PMID: 36838267 PMCID: PMC9961354 DOI: 10.3390/microorganisms11020302] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
Human adenovirus causes infections with a very heterogeneous clinical picture, and children are often the most frequently affected group. Interest in adenovirus has increased with the 2022 outbreak of severe acute hepatitis of unknown etiology as human adenovirus was considered as one of the possible etiological agents. We conducted a retrospective study over a 5-year period in two major tertiary hospitals in the Romanian capital with the aim to characterize the clinical picture and the dynamics of liver function tests in children with confirmed adenovirus infection. The study included 1416 children with a median age of 1.1 years (IQR: 0.3, 2.3 years). Digestive symptoms were predominant in 95.2% of children, mainly diarrhea (90.5%) and vomiting (50.5%), and 38.0% had respiratory symptoms. Increased transaminases were identified in 21.5% of patients. Age over 1 year, lethargy, vomiting and dehydration significantly increased the odds of liver cytolysis independent of other risk factors such as chronic conditions or co-infections. Aspartate aminotransferase (AST) was more commonly increased compared to alanine aminotransferase (ALT). Only six children had transaminase increases above 500 U/L, three of which had co-infections with rotavirus, Epstein-Barr virus (EBV), or respiratory syncytial virus (RSV). Liver function tests should be part of routine monitoring for pediatric patients with adenovirus infection. The current study fills a gap in current knowledge related to the frequency and the extent of liver involvement in human adenovirus infection among pediatric patients.
Collapse
Affiliation(s)
- Oana Săndulescu
- Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, 021105 Bucharest, Romania
| | - Anca Streinu-Cercel
- Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, 021105 Bucharest, Romania
| | - Victor Daniel Miron
- Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- National Institute of Mother and Child Health “Alessandrescu-Rusescu”, 020395 Bucharest, Romania
- Correspondence:
| | - Silvia Mirela Covăcescu
- Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- National Institute of Mother and Child Health “Alessandrescu-Rusescu”, 020395 Bucharest, Romania
| | - Adrian Streinu-Cercel
- Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, 021105 Bucharest, Romania
| | - Mihai Craiu
- Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- National Institute of Mother and Child Health “Alessandrescu-Rusescu”, 020395 Bucharest, Romania
| |
Collapse
|
6
|
Singh R, Kapoor A. Severe Acute Hepatitis: An Emerging Grave Illness in Children. Indian Pediatr 2023; 60. [PMCID: PMC10052219 DOI: 10.1007/s13312-023-2831-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Acute hepatitis of unknown origin in children has been recently described in the literature, and a case definition has also been proposed for this condition. The exact etiology is unknown and exclusion of infectious, metabolic, autoimmune and toxin mediated injuries is essential. Management for this condition is supportive, but some may require liver transplantation. Infection prevention and control practices are important as the etiology remains unidentified.
Collapse
Affiliation(s)
- Raghvendra Singh
- Department of Pediatrics, Maulana Azad Medical College (University of Delhi) and Lok Nayak Hospital, New Delhi, India
- Department of Pediatrics, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi, 110 002 India
| | | |
Collapse
|
7
|
Alexander EC, Deep A. Characterization of a Hepatitis Outbreak in Children, 2021 to 2022. JAMA Netw Open 2022; 5:e2237091. [PMID: 36255724 PMCID: PMC9579900 DOI: 10.1001/jamanetworkopen.2022.37091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/31/2022] [Indexed: 12/19/2022] Open
Abstract
Importance After a cluster of pediatric cases of hepatitis of unknown etiology were identified in Scotland in March 2022, the World Health Organization published an outbreak alert, and more than 1010 probable cases were reported. Some cases progressed to acute liver failure and required liver transplant. Although many patients had positive results for adenovirus on polymerase chain reaction testing from whole blood samples and/or reported recent COVID-19 infection (with or without seropositivity), the precise pathogenesis remains unclear despite the high potential morbidity of this condition. Objective To summarize the currently available evidence regarding novel pediatric hepatitis of unknown etiology (or novel hepatitis), encompassing case numbers, testing, management, and outcomes. Evidence Review A rapid review of the literature from April 1, 2021, to August 30, 2022, aimed to identify all available published case series and case-control studies of novel hepatitis. The search included PubMed and references and citations of short-listed studies. Findings A total of 22 available case series and case-control studies describing 1643 cases were identified, with 120 children (7.3%) receiving liver transplants and 24 deaths (1.5%). Outcome reporting and testing for adenovirus and SARS-CoV-2 was incomplete. Assessment of disease severity and management was mixed and results regarding testing for adenovirus and SARS-CoV-2 were inconsistent for both serological testing and testing of explant or biopsy liver samples. More recent studies suggest a more plausible role for adenovirus and/or adeno-associated virus 2. Conclusions and Relevance This systematic review without meta-analysis describes the challenge posed by hepatitis of unknown etiology in terms of investigation and management, with many cases progressing to acute liver failure. The lack of clarity regarding pathogenesis means that these children may be missing the potential for targeted therapies to improve outcomes and avert the need for transplant. Clinicians, immunologists, and epidemiologists must collaborate to investigate the pathogenesis of this novel hepatitis.
Collapse
Affiliation(s)
- Emma C. Alexander
- Paediatric Intensive Care Unit, King’s College Hospital NHS (National Health Service) Foundation Trust, London, United Kingdom
| | - Akash Deep
- Paediatric Intensive Care Unit, King’s College Hospital NHS (National Health Service) Foundation Trust, London, United Kingdom
| |
Collapse
|